Staffing and Nursing Care Hour Deficiencies
Penalty
Summary
The facility failed to meet the required staffing levels and minimum nursing care hours as mandated by regulations. Specifically, the facility did not provide the necessary number of Licensed Practical Nurses (LPNs) per resident during various shifts, with no additional higher-level staff to compensate for this deficiency. Additionally, the facility did not meet the minimum requirement of 3.2 hours of direct resident care per resident in a 24-hour period on 11 out of 21 days. This was confirmed through a review of nursing time schedules and staff interviews, as well as census data, which showed that the facility consistently fell short of the required nursing care hours on specific dates.
Plan Of Correction
The facility will continue to maintain the required 3.2 nursing ratios in a 24-hour period and implement a contingency plan if needed by calling in off duty staff, calling sister facilities or utilizing agency as needed to ensure sufficient nursing staff. The RDCS educated NHA/DON/scheduler on ensuring sufficient nursing staff. To monitor and maintain ongoing compliance, the NHA/DON/scheduler will complete staffing meetings 2x daily x 5x weekly x 4 weeks, then 1x daily x 5x weekly ongoing thereafter to ensure sufficient nursing staff. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.